Apparatus and method for resectioning gastro-esophageal tissue

ABSTRACT

A system for stapling tissue comprises a flexible endoscope and an operative head including a pair of opposed, curved tissue clamping jaws sized to pass through an esophagus, the jaws being moveable with respect to one another between an open tissue receiving configuration and a closed tissue clamping configuration, a first one of the curved jaws including a stapling mechanism and a second one of the jaws including a staple forming anvil surface, the stapling mechanism including staple slots through which staples are fired arranged in a row extending from a proximal end of the first jaw to a distal end thereof in combination with a control handle which, when the operative head is in an operative position within one of a patient&#39;s stomach and esophagus, remains outside the patient, the control handle including a first actuator for moving the jaws relative to one another and a second actuator for operating the stapling mechanism.

This application is a Continuation of U.S. patent application Ser. No.10/855,908, entitled “Apparatus and Method for ResectioningGastro-esophageal Tissue” filed May 27, 2004 which is a divisionalapplication of U.S. patent application Ser. No. 10/062,760 filed Jan.31, 2002 which claims benefit of U.S. Provisional Patent ApplicationSer. No. 60/265,469 filed on Jan. 31, 2001. The entire disclosures ofthese prior applications are considered part of the disclosure of theaccompanying application and is hereby expressly incorporated byreference herein.

FIELD OF THE INVENTION

The present invention relates to endoscopic devices for performinglocalized resections of gastro-esophageal lesions.

BACKGROUND OF THE INVENTION

Endoscopic surgical stapling apparatus are known in the art and areutilized to provide a variety of surgical procedures. For example, U.S.Pat. No. 5,040,715 to Green, et al. discloses an endoscopic staplingdevice configured to be inserted through a small entrance wound in theabdominal cavity to place rows of staples in body tissue. This devicehas a limited range of motion in that the stapling assembly at thedistal end of the instrument can only be rotated about the central axisof the instrument.

An endoscopic stapling apparatus purporting to have a greater range ofmotion is disclosed in U.S. Pat. No. 5,326,013 to Green et al. Thisdevice has an articulating stapling assembly mounted for pivotalmovement about an axis extending transverse to the central axis of theinstrument. An endoscopic stapling device designed to be insertedthrough a small incision in a body wall and purporting to have anincreased range of motion is described in U.S. Pat. No. 5,389,098 toTsuruta et al. A stapling assembly of this device curves away from acentral axis of the instrument to a 90 degree angle so that it can moreeasily reach tissue spaced from the central axis. This device incisestissue clamped within the stapling assembly and places staggered linesof staples on both sides of the incision.

SUMMARY OF THE INVENTION

The present invention is directed to a system for stapling tissuecomprising a flexible endoscope and an operative head including a pairof opposed, curved tissue clamping jaws sized to pass through anesophagus, the jaws being moveable with respect to one another betweenan open tissue receiving configuration and a closed tissue clampingconfiguration, a first one of the curved jaws including a staplingmechanism and a second one of the jaws including a staple forming anvilsurface, the stapling mechanism including staple slots through whichstaples are fired arranged in a row extending from a proximal end of thefirst jaw to a distal end thereof in combination with a control handlewhich, when the operative head is in an operative position within one ofa patient's stomach and esophagus, remains outside the patient, thecontrol handle including a first actuator for moving the jaws relativeto one another and a second actuator for operating the staplingmechanism.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 shows a perspective view of a system according to an illustrativeembodiment of the present invention along with a partiallycross-sectional view of a patient showing a target portion of tissue tobe resected;

FIG. 2 a shows the system of FIG. 1 inserted into the patient's body viathe mouth;

FIG. 2 b shows a display of the image of a stapling apparatus of thesystem of FIG. 1 provided to a user;

FIG. 2 c shows a cross-sectional view of the patient's esophagus withthe stapling apparatus of FIG. 3 in position adjacent to the targetportion of tissue;

FIG. 3 shows a perspective view of the system of FIG. 1 with jaws of thestapling apparatus open;

FIG. 4 shows a partially cross-sectional view of a proximal end of thestapling apparatus of FIG. 3 showing control cables for operating thejaws configured as when the jaws are open;

FIG. 5 shows a perspective view of the system of FIG. 1 with jaws of thestapling apparatus closed with a lower actuator lever on a controlhandle being actuated;

FIG. 6 shows a partially cross-sectional view of the control handle ofthe system of FIG. 5 showing a coupling between control cables foroperating the jaws and the lower actuator lever on the control handle;

FIG. 7 shows a partially cross-sectional view of a proximal end of thestapling apparatus of FIG. 5 showing control cables for operating astapling pusher of the stapling apparatus configured as when the loweractuator lever is actuated;

FIG. 8 shows a perspective view of the system of FIG. 1 with jaws of thestapling apparatus closed with an upper actuator lever on the controlhandle being actuated;

FIG. 9 shows a partially cross-sectional view of a portion of thecontrol handle of the system of FIG. 8 showing a coupling betweencontrol cables for operating the jaws and the upper actuator lever onthe control handle;

FIG. 10 shows a partially cross-sectional view of a proximal end of thestapling apparatus of FIG. 5 showing control cables for operating astapling pusher of the stapling apparatus configured as when the upperactuator lever is actuated;

FIG. 11 shows a partially cross-sectional view of a stapling assembly ofthe system of FIG. 1 grasping esophageal tissue;

FIG. 12 shows a partially cross-sectional view of the stapling assemblyof the system of FIG. 1 illustrating a mechanism for grosslyapproximating the jaws of the stapling assembly;

FIG. 13 shows a partially cross-sectional view of the stapling assemblyillustrating a mechanism for finely approximating the jaws in an initialposition;

FIG. 14 shows a perspective view of an I-beam member of the fineapproximation mechanism of FIG. 13;

FIG. 15 shows a partially cross-sectional view of the stapling assemblywith the fine approximation mechanism in a partially advanced position;

FIG. 16 shows a perspective view of the stapling assembly with aC-shaped clamp member thereof in an initial position;

FIG. 17 shows a perspective view of the C-shaped clamp member of FIG. 16rotated 180 degree removed from the jaws;

FIG. 18 shows a cross-sectional view of the stapling assembly with theC-shaped clamp member in a partially advanced position;

FIG. 19 shows an alternate embodiment of the system according to thepresent invention with a lateral endoscope receiving lumen;

FIG. 20 shows the system of FIG. 19 with an endoscope received therein;

FIG. 21 shows a system in accord with the present invention positionedwithin the stomach to perform a procedure for the treatment of reflux;and

FIG. 22 shows a system in accord with the present invention positionedwithin the stomach to perform a stomach reduction procedure.

DETAILED DESCRIPTION

A detailed description of illustrative embodiments of the presentinvention is provided in conjunction with the attached drawings. In thedescriptions of the various embodiments and the corresponding drawings,like reference numerals refer to like elements.

A method and apparatus for resectioning anastomized lumenal tissue isdisclosed in U.S. Pat. No. 5,868,760 to McGuckin et al., the disclosureof which is hereby incorporated by reference in its entirety. Thedisclosed apparatus includes a flexible tubular body and a distaloperating capsule that may be inserted through either a naturallyoccurring body orifice or a surgical incision and guided to an operativesite endoscopically or using radiologic imaging guidance. In use thetarget tissue is stapled, cut and captured within the operating capsulefor removal from the body. The healthy tissue is thereby anastomized bysurgical staples.

FIG. 1 shows a system for resecting esophageal tissue according to anillustrative embodiment of the present invention. A surgical staplingapparatus, designated generally by the reference numeral 10, is utilizedin conjunction with an endoscope 20 for providing remote vision of anoperative area and to assist in guiding the stapling apparatus 10 to theoperative area. An endoscopic grasping device 30 extends through a lumenin the endoscope 20 for use at the surgical site as would be understoodby those of skill in the art. Those skilled in the art will furtherunderstand that, while the illustrative embodiments are described inconjunction with visual observation of the operative site via theendoscope 20, these procedures may also be visualized through the use ofMagnetic Resonance Imaging (MRI). In this case, components of the systemand the instruments utilized therewith, such as the grasping device 30,would be constructed from non-ferrous material such as titanium, aswould be understood by those of skill in the art.

As shown in FIG. 1, the stapling apparatus 10 includes a proximal handleportion 12, an elongated flexible body portion 14 extending from thehandle portion 12 and a generally C-shaped stapling assembly 16operatively associated with a distal end of the flexible body portion14. The flexible body portion 14 and the stapling assembly 16 arepreferably dimensioned and configured to traverse the natural curvatureof the esophagus. As shown in FIGS. 2 b and 2 c and described in detailbelow, the stapling assembly 16 includes a pair of opposable jaws 17defined by a staple carrying portion 40 and a staple forming portion 50.Those skilled in the art will understand that, although the jaws 17 aredescribed herein as rotating relative to one another between the openand closed positions, that these jaws 17 may be coupled by a mechanismwhich allows them to move linearly with respect to one another or in anyother manner so long as they move between a first position in which thejaws 17 are separated from one another to receive tissue and a secondposition in which the jaws 17 are clamped together to hold tissuetightly therebetween for stapling.

Furthermore, those skilled in the art will understand that the systemmay operate with any of a variety of commercially available medicalendoscopes which may include, for example, a proximal handle portion 22,an elongated flexible body portion 24 through which one or more interiorlumena extend for accommodating, for example, a fiber optic bundle orother image transmission structure, a working channel for the graspingdevice 30, etc. Those skilled in the art will understand that the fiberoptic bundle (or other image transmitting structure) allows a user toremotely visually monitor a field of view at the distal end of theendoscope (e.g., an operative site S within the esophagus E). As wouldbe further understood by those of skill in the art, the tissue graspingdevice 30 may include a handle portion 32, an elongated flexible bodyportion 34 and a pair of opposable jaws 36, which consists of first andsecond opposable jaws 36 a and 36 b.

In use as shown in FIGS. 2 a-2 c, the surgical stapling apparatus 10 andthe flexible endoscope 20 are introduced into a patient's mouth andadvanced into the esophagus to the operative site S under visualguidance from the endoscope 20. Once at the site S, the operatormaneuvers the stapling assembly 16 into a desired position relative tothe tissue to be resected. Those skilled in the art will understand thatthe stapling assembly 16 may be coupled to the handle portion 22 by acable steering system (not shown) substantially as included incommercially available endoscopes to allow the remote maneuvering andpositioning of the stapling assembly 16. The jaws 17 of the staplingassembly 16 are then opened to a tissue receiving position as shown inFIG. 3 and the grasping device 30 is advanced from the distal end of theendoscope 20. The jaws 36 a and 36 b are rotated away from one anotherby manipulation of the grasper handle portion 32 and the tissue T to beresected is grasped by closing the jaws 36 a, 36 b. The grasping device30 is then withdrawn into the working channel of the endoscope 20 topull the tissue T into position between the jaws 17 of the staplingassembly 16 and the jaws 17 are closed to clamp the tissue T in placebetween the staple carrying portion 40 and the staple forming portion50. Those skilled in the art will understand that the tissue T ispreferably drawn between the jaws 17 so that a margin of healthy tissueis positioned between the staple carrying portion 40 and the stapleforming portion 50 to ensure that all of the diseased or damaged tissueT is removed. Those skilled in the art will understand that this may bevisually confirmed through the use of a vision system 55 of theendoscope as shown in FIG. 2 b.

As shown in FIG. 2 c, once the tissue T has been properly positionedbetween the jaws 17, the jaws 17 are grossly approximated and are thenfinely approximated using a translating clamping member 60, illustratedin detail in FIGS. 16-18. As shown in FIGS. 3, 4 and 12, an illustrativeembodiment of the system according to the present invention includes anactuation cable 44 to facilitate gross approximation of the jaws 17 viaactuation of an actuator knob 38. The actuation cable 44 may be securedto the one of the jaws 17 including, for example, the staple carryingportion 40 by a member 75, which may, for example be a spindle, capstanor other member around which cable 44 loops. The cable 44 is operativelycoupled to the other jaw 17 including the staple forming portion 50 by amember 85, which is substantially similar to the member 75 and aroundwhich the cable 44 passes to change direction to generate the clampingforce to draw the jaws 17 together. Furthermore, an overhanging flange98 at a proximal end of the staple carrying portion 40 acts as a tissueshield preventing the target tissue T from entering into the jointbetween the jaws 17.

As shown in FIGS. 3-7, to actuate the clamping member 60 to finelyapproximate the jaws 17, the lower clamping handle 12 a is actuated inthe direction of the arrow in FIG. 5 to cause the integral gear rack 62a to turn pinion gear 62 b which rotates elongated drive cable 64. Asshown in FIG. 7, the drive cable 64 is coupled to a drive screw 63interacting with a geared surface 65 so that rotation of the drive cable64 rotates the drive screw 63 moving the clamping member 60 distally asshown in FIG. 18. This finely approximates the jaws 17 of the staplingassembly 16 whereby a tissue contacting surface of the staple carryingportion 40 and a tissue contacting surface of the staple forming portion50 are brought into cooperative alignment, tightly clamping the tissuetherebetween. Those skilled in the art will understand that alternativesources of power (e.g., electrical, hydraulic, pneumatic, etc.) may beapplied to drive the jaws 17 and to drive all other mechanisms of thestapling assembly 16.

As shown in FIG. 8, once the jaws 17 have been brought into cooperativealignment with one another, the stapling assembly 16 may be actuated tofire staples through the clamped tissue while simultaneously cuttingaway the tissue T from the stapled and anastamized tissue. The useractuates the stapling assembly 16 to drive staples through the margin ofhealthy tissue in one or more arcuate bands located radially outward ofa line of tissue cutting. Alternatively, those skilled in the art willunderstand that the stapling operation may be separated from the tissuecutting operation so that no tissue is cut until the entire staplingoperation has been successfully concluded.

Specifically, as shown in FIGS. 8-10, the operator drives an I-beammember 70 through the stapling assembly 16 by operating the clampinghandle 12 b in the direction of the arrow in FIG. 8, causing gear rack72 a to rotate pinion gear 72 b which rotates a staple driving drivecable 74 as shown in FIG. 9. The drive cable extends through theflexible body portion 14 to a linear drive screw 76 which drives aflexible pusher 80 coupled to the I-beam member 70 as shown in FIG. 10.

As shown in FIGS. 11, 13, 14 and 15, the I-beam member 70 includes upperand lower beam portions 82 a, 82 b, respectively, connected by a centralweb portion 84. A leading edge 84a of the central web portion 84 maypreferably define a cutting blade for incising tissue as the I-beammember 70 is moved distally as described below. As shown in FIG. 11, anarcuate channel 90 within which the central web portion 84 travels, isdefined in the opposing jaws 17 radially inward of the arcuate lines ofstaple carrying slots (not shown). Those skilled in the art willunderstand that the staple slots may be arranged in any number of rows,for example, from one to five such rows may be included and the slots ofthese rows may be staggered so that to ensure that the opening createdby the resection is completely sealed.

As described above, actuation of the lower handle 12 a causes theC-shaped clamp member 60 to move along an arc the length of the curvedstapling assembly 16 to finely approximate the jaws 17 toward oneanother. As shown in FIGS. 13, 14 and 15, the clamp member 60 includes abody portion 112 from which depend upper and lower clamping beams 114 aand 114 b, respectively, for urging the jaws 17 toward one another.

In addition, as shown in FIGS. 16 and 17, in one embodiment of theinvention, the body 112 includes a radially depending driving stem 115having a sloped leading edge configured to extend through an arcuateslot 116 formed in the staple carrying portion 40 for sequentiallycontacting each of a plurality of staple pushers 118. The staple pushers118 are positioned so that, when contacted by the driving stem 115, eachstaple pusher 118 is driven through a corresponding one of the stapleslots to drive a staple housed therein from the slot out of the staplecarrying portion 40, through both thicknesses of the folded portion oftissue clamped between the jaws 17 and against the staple formingsurface 50 a of the staple forming portion 50 to couple the twothicknesses of tissue to one another. In this embodiment, the clampingmember 60 further includes an integral cutting blade 130 for forming anarcuate incision substantially concentric with and radially within aninner one of the arcs of staple slots. Furthermore, the cutting blade130 is preferably positioned so that it trails the leading edge 115 sothat tissue is stapled before it is cut.

As shown in FIG. 15, according to a further embodiment of the invention,actuation of the upper actuation handle 12 b causes the I-beam member 70to move through the stapling assembly 16 to sequentially fire arcuaterows of staples while simultaneously cutting tissue away from theesophagus radially within the rows of staples. When the I-beam member 70is driven by the pusher 80, the sloped leading edge of the upper beamportion 82 a contacts sequentially each of a plurality of staple pushers118 to drive them through their respective staple slots to drive thestaples housed therein from each slot out of the staple carrying portion40, through both thicknesses of the folded portion of tissue clampedbetween the jaws 17 and into the staple forming pockets 122 formed inthe staple forming surface 50 a of the staple forming portion 50 tocouple the two thicknesses of tissue to one another. As the leading edge84 a of the central web portion 84 is proximal to the sloped leadingedge, the incision trails the stapling action so that only tissue withinthe arc that has previously been stapled is severed.

As shown in FIGS. 19 and 20, according to a further embodiment of theinvention, a stapling assembly 16′ according to the present inventionmay include an endoscope receiving lumen 140 through which the endoscope20 may be slidably inserted. This allows an operator to use to steeringand vision capability of the endoscope 20 to locate the operative siteS. Once the distal end of the endoscope 20 is positioned adjacent to thesite S, the stapling assembly 16′ may be slid along the endoscope 20 tothe operative site S and the steering capability of the distal end ofthe endoscope 20 may be employed to achieve a desired position andorientation of the stapling assembly 16′ relative to the tissue T. Otherthan the endoscope receiving lumen 140, the construction of the rest ofthe system of FIGS. 19 and 20 may be substantially in accord with thatof any of the previously described embodiments.

Furthermore, as shown in FIGS. 21 and 22, the system according to thepresent invention may also be used to perform resections within thestomach. For example, the stapling apparatus 10 may be used to correctgastro-esophageal reflux (“GERD”) or to perform a stomach reductionprocedure. Specifically, as shown in FIG. 21, a system according to theinvention may be inserted through the esophagus into a patient's stomachand the operator may position the jaws 17 under visual control via theendoscope 20 adjacent to a junction between the esophagus and thestomach. The operator then uses the steering capability of the endoscope20, received within the endoscope lumen 140 to direct the jaws 17 towarda portion of stomach tissue to be fastened to the esophagus.Specifically, the operator grasps a portion of the stomach using thegrasping device 30 and urges the tissue T toward the esophagus to createa fold of tissue with an outside surface of the stomach tissue adjacentto or in contact with an outer surface of the esophagus. This fold isthen clamped by the jaws 17 and stapled together to reduce the diameterof the opening from the esophagus to the stomach. The tissue radiallywithin the stapled tissue is then resected.

Similarly as shown in FIG. 22, to perform a stomach reduction, anoperator inserts a system according to the present invention into thestomach via the esophagus as described above in regard to FIG. 21 andlocates a portion of tissue to be folded over on itself to reduce thesize of the stomach. This tissue T is grasped by the grasping device 30and drawn between the jaws 17 which clamp the tissue T together foldedonto itself and staples the fold together. Those skilled in the art willunderstand that, for a stomach reduction procedure, the folded tissueradially within the staples may, if desired, be left in place withoutresection so that the operation may be reversed at a later date. Thus,for such a stomach reduction procedure where the folded, stapled tissuewill be left in place within the stomach, the stapling apparatus 10 neednot include a tissue cutting mechanism. Rather, the stapling apparatus10 need only include structure for approximating the jaws 17 and fordriving staples through the gripped fold of tissue. In this case, theC-shaped clamp member 60 would be constructed without the cutting blade130.

The above described embodiments are for purposes of illustration onlyand the various modifications of these embodiments which will beapparent are considered to be within the scope of the teachings of thisinvention which is to be limited only by the claims appended hereto.

1. A system for stapling tissue, comprising: a stapling head includingfirst and second jaws movable with respect to one another between atissue receiving configuration and a tissue stapling configuration, thefirst jaw including a stapling mechanism and the second jaw including astaple forming surface, the stapling head further including gross andfine movement mechanisms controlling gross and fine movements,respectively, of one of the first and second jaws relative to the otherof the first and second jaws; and a control unit including a firstactuator controlling the gross and fine movement mechanisms and a secondactuator operating the stapling mechanism.
 2. The system according toclaim 1, wherein the fine movement mechanism includes a clamp receivedaround the first and second jaws, wherein the first actuator controlsproximal and distal movement of the clamp for controlling fine movementof the first and second jaws.
 3. The system according to claim 2,wherein the clamp is substantially C-shaped.
 4. The system according toclaim 1, wherein the gross movement mechanism includes a cable fixed ata first end to the first jaw, threaded around a spindle in the secondjaw and fixed at a second end to the first actuator.
 5. The systemaccording to claim 1, wherein the stapling mechanism includes staplingslots arranged in a row extending from a proximal end to a distal end ofthe first jaw, each of the stapling slots including a staple.
 6. Thesystem according to claim 5, wherein the first jaw includes a staplepusher driving staples in the stapling slots successively against thestaple forming surface of the second jaw as the staple pusher moves fromthe proximal end toward the distal end of the first jaw.
 7. The systemaccording to claim 6, wherein the stapling head further defines a firstsurface which, when in the tissue stapling configuration, abuts targettissue, and wherein the stapling head includes a tissue cutter cuttingon a side of the stapling head opposite the first surface.
 8. The systemaccording to claim 7, wherein the tissue cutter is disposed on aproximal end of the staple pusher.
 9. The system according to claim 6,wherein the stapling mechanism includes further stapling slots arrangedin a further row substantially parallel to the row of the staplingslots.
 10. The system according to claim 9, wherein the tissue cuttercuts tissue between the row and the further row.
 11. A method forstapling tissue, comprising the steps of: inserting into a body tissueresectioning device including a stapling head having a first jawincluding a stapling mechanism and a second jaw including a stapleforming surface; drawing a fold of tissue between the first and secondjaws; actuating a gross movement mechanism to move the first and secondjaws toward a desired tissue stapling configuration compressing the foldbetween the first and second jaws; actuating a fine movement mechanismin the stapling head to finely adjust a position of the first and secondjaws to the desired tissue stapling configuration; and actuating thestapling mechanism to drive staples through the fold and against thestaple forming surface.
 12. The method according to claim 11, whereinthe step of actuating the fine movement mechanism includes: slidingdistally a clamp over the first and second jaws.
 13. The methodaccording to claim 12, wherein the clamp is substantially C-shaped. 14.The method according to claim 11, wherein the step of actuating thestapling mechanism includes: driving staples from stapling slotsarranged in a row in the first jaw to form a row of staples in the fold.15. The method according to claim 14, further comprising: cutting tissueradially within the row of staples.
 16. The method according to claim15, wherein the driving step includes: moving a staple pusher in thefirst jaw distally to drive staples in the stapling slots successivelythrough the fold and against the staple forming surface of the secondjaw.
 17. A system for stapling tissue, comprising: a stapling headincluding first and second jaws moveable with respect to one anotherbetween a tissue receiving configuration and a tissue staplingconfiguration, the first jaw including a stapling mechanism and thesecond jaw including a staple forming surface, the stapling head furtherincluding gross and fine movement mechanisms altering a distance betweenthe first and second jaws; a control unit including a first actuatorcontrolling the gross and fine movement mechanisms and a second actuatoroperating the stapling mechanism; and a flexible shaft coupling thecontrol unit to the stapling head.
 18. The system according to claim 17,wherein the stapling head is slidably coupleable to an endoscope. 19.The system according to claim 18, wherein the flexible shaft includes adrive cable having a first end coupled to the first actuator and asecond end couple to the fine movement mechanism.
 20. The systemaccording to claim 19, wherein the stapling head includes a translationarrangement translating rotation of the drive cable into linear movementof a clamp received around the first and second jaws.
 21. The systemaccording to claim 20, wherein the clamp is substantially C-shaped. 22.The system according to claim 17, wherein the flexible shaft includes anactuation cable having a first end coupled to the first actuator and asecond end coupled to the gross movement mechanism.
 23. The systemaccording to claim 22, wherein the actuation cable is fixed at thesecond end to the first jaw and threaded around a spindle in the secondjaw, wherein the first actuator controls a proximal force applied to thecable for controlling gross movement of the first and second jaws.
 24. Amethod for reducing a volume of a stomach, comprising: inserting andendoscope into the stomach; sliding a tissue resectioning device alongthe endoscope into the stomach, the tissue resectioning device includinga stapling head having a first jaw including a stapling mechanism and asecond jaw including a staple forming surface, the stapling head furtherincluding a tissue cutting mechanism; drawing a fold of tissue betweenthe first and second jaws; actuating a gross movement mechanism in thestapling head to move the first and second jaws toward a desired tissuestapling configuration so that the fold is compressed between the firstand second jaws to the desired tissue stapling configuration; actuatinga fine movement mechanism in the stapling head to finely adjust aposition of the first and second jaws; actuating the stapling mechanismto drive staples through the fold and against the staple formingsurface; and actuating the tissue cutting mechanism to resect a portionof the fold.